Time to endovascular reperfusion and degree of disability in acute stroke

Abstract

Objective Faster time from onset to recanalization (OTR) in acute ischemic stroke using endovascular therapy (ET) has been associated with better outcome. However, previous studies were based on less-effective first-generation devices, and analyzed only dichotomized disability outcomes, which may underestimate the full effect of treatment. Methods In the combined databases of the SWIFT and STAR trials, we identified patients treated with the Solitaire stent retriever with achievement of substantial reperfusion (Thrombolysis in Cerebral Infarction [TICI] 2b–3). Ordinal numbers needed to treat values were derived by populating joint outcome tables. Results Among 202 patients treated with ET with TICI 2b to 3 reperfusion, mean age was 68 (±13), 62% were female, and median National Institutes of Health Stroke Scale (NIHSS) score was 17 (interquartile range [IQR]: 14– 20). Day 90 modified Rankin Scale (mRS) outcomes for OTR time intervals ranging from 180 to 480 minutes showed substantial time-related reductions in disability across the entire outcome range. Shorter OTR was associated with improved mean 90-day mRS (1.4 vs. 2.4 vs. 3.3, for OTR groups of 124–240 vs. 241–360 vs. 361–660 minutes; p < 0.001). The number of patients identified as benefitting from therapy with shorter OTR were 3-fold (range, 1.5–4.7) higher on ordinal, compared with dichotomized analysis. For every 15-minute acceleration of OTR, 34 per 1,000 treated patients had improved disability outcome. Interpretation Analysis of disability over the entire outcome range demonstrates a marked effect of shorter time to reperfusion upon improved clinical outcome, substantially higher than binary metrics. For every 5-minute delay in endovascular reperfusion, 1 of 100 patients has a worse disability outcome.

Predictive Value of Modifications of the Prehospital Rapid Arterial Occlusion Evaluation Scale for Large Vessel Occlusion in Patients with Acute Stroke

“…The RACE scale score was not detailed item-by-item in 16 cases and therefore we studied 341 patients (53.4% men; age (mean±SD) 70±13 years; NIHSS score at admission (median [interquartile range] 8 [3][4][5][6][7][8][9][10][11][12][13][14][15][16] had 85% sensitivity, 68% specificity and correctly classified 71% patients. The RACE and NIHSS scores were strongly correlated (r=0.78; p<0.001).…”

“…However, benefit declines with increasing time after symptom onset (6).Transferring patients from a Primary Stroke Center (PSC) to a Comprehensive Stroke Center (CSC) commonly delays endovascular treatment (7). A pre-hospital clinical tool to detect LVO patients and facilitate rapid transport directly to a CSC is therefore of crucial importance.…”

Clinical and Procedural Predictors of Outcomes From the Endovascular Treatment of Posterior Circulation Strokes

“…The strong effect of time to intervention and reperfusion on clinical outcomes is well described in anterior circulation strokes. This includes the recent analysis of SWIFT and Solitaire FR Thrombectomy for Acute Revascularisation (STAR) trials, 13 studies focusing on early generation thrombectomy approaches, such as the IMS III data set analysis, 14 and the pooled analysis of the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) and Multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI) trials. 15 However, there was no effect of time to the start of intervention on the rate of successful recanalization in our series, which remained consistently around 80%.…”

Clinical Scales Do Not Reliably Identify Acute Ischemic Stroke Patients With Large-Artery Occlusion

“…Inclusion criteria for the present study were (1) magnetic resonance angiography (MRA) or computed tomographic angiography (CTA) performed on admission; and (2) ischemic stroke proven on diffusion-weighted imaging or follow-up CT scan. Exclusion criteria were (1) unknown time of symptom onset; (2) missing admission NIHSS score items; (3) previous stroke with significant disability (modified Rankin Scale score, >1); (4) insufficient quality of MRA or CTA to assess LAO status; (5) patients transferred from a primary stroke center to receive endovascular therapy, as including such patients would lead to an unusually high prevalence of LAO.…”

“…[1][2][3] Although thrombectomy has been shown to be superior to best medical treatment ≤6 hours after stroke onset, it should be started as early as possible because time to endovascular reperfusion is strongly associated with long-term outcome. 4 Ideally, therefore, AIS patients with suspected LAO should be sent to the nearest comprehensive stroke center (CSC) with neurointerventional facilities at the earliest opportunity, whereas patients with AIS unlikely to have an LAO should be referred to primary stroke centers, hence avoiding overwhelming CSCs with inappropriate transfers. 5 Several dedicated clinical scores, as well as National Institute of Health Stroke Scale (NIHSS) score cutoffs, have been proposed to help predict LAO in patients with suspected AIS and might be used for prehospital triage.…”